Cardiovascular emergencies in cruise ship passengers.

More than 10 million people, many elderly and likely to harbor cardiovascular (CV) disease, embark on cruise ship travel worldwide every year. The clinical presentation and outcome of CV emergencies presenting during cruise ship travel remain largely unknown. Our department provides contracted cardiology consultations to several large cruise lines. We prospectively maintained a registry of all such consultations during a 2-year period. One hundred consecutive patients were identified (age 66 +/- 14 years, range 18 to 90, 76% men). The most common symptom was chest pain (50%). The most common diagnosis was acute coronary syndrome (58%; ST elevation in 21% and non-ST elevation in 37%). On-board mortality was 3%. Overall, 73% of patients required hospital triage. Of the 25 patients triaged to our institution, 17 underwent a revascularization procedure. One patient died. Ten percent of patients had cardiac symptoms in the days or weeks before boarding; all required hospital triage. Access to a baseline electrocardiogram would have been clinically useful in 23% of cases. In conclusion, CV emergencies, such as acute coronary syndrome and heart failure, are not uncommon on cruise ships. They are often serious, requiring hospital triage and coronary revascularization. A pretravel medical evaluation is recommended for passengers with a cardiac history or a high-risk profile. Passengers should be encouraged to bring a copy of their electrocardiogram on board if abnormal. Cruise lines should establish mechanisms for prompt consultation and triage.

Reclassification of patients for aggressive cholesterol treatment: additive value of multislice coronary angiography to the National Cholesterol Education Program guidelines.

BACKGROUND: National Cholesterol Education Program (NCEP) guidelines have been used to define treatment goals in patients with hypercholesterolemia. However, epidemiology-based guidelines are unable to identify all subjects with coronary artery disease for aggressive lipid intervention. OBJECTIVE: We sought to evaluate the additive value of multislice computed tomography (MSCT) angiography to the NCEP guideline classification for lipid treatment. METHODS: Multislice computed tomography was performed in 114 consecutive patients (mean age 57+/-14 y; 59% male) without known coronary artery disease. Subjects were classified into 3 categories (low-, intermediate-, and high-risk) according to their Framingham risk scores (FRS). RESULTS: Traditional cardiac risk factors were common: hypertension 59%, diabetes 13%, and smoking 22%. On the basis of the FRS, 11% (n=12/114) of the patients met high-risk criteria requiring aggressive cholesterol reduction. Of those in the low- and intermediate-risk groups, MSCT found coronary plaque in 76% (n=77/102), with moderate or severe plaque in 38% (n=39/102), thus reclassifying them in the high-risk category. Use of statin drugs increased from 32% at baseline to 53% (p=0.002) based on MSCT results; statin dose was increased in 31% of the patients who were already on a statin. The mean low-density lipoprotein cholesterol (LDL-c) decreased from 114 mg/dL to 91 mg/dL after MSCT (p<0.001). CONCLUSION: Multislice computed tomography reclassifies a high percentage of patients considered to be low- to intermediate-risk into the high-risk category based on their coronary artery lesions. Thus, the rise in MSCT use at present may have a large impact on clinician practice patterns in lipid-lowering therapy.

Use of the prehospital ECG improves door-to-balloon times in ST segment elevation myocardial infarction irrespective of time of day or day of week.

BACKGROUND: The use of the prehospital electrocardiogram (ECG) to identify patients with ST-segment elevation myocardial infarction (STEMI), coupled with a centralised system to alert the cardiac catheterisation team in preparation for prompt intervention, has been shown to reduce door-to-balloon times (DBT) effectively. A confounding variable in prolonging the recommended 90 min DBT is the time of day or day of the week of patient presentation. We postulated that use of the prehospital ECG, coupled with an emergency department initiated "Cath Alert" system, could neutralise DBT delays related to time of day or day of week. METHODS: A prospective study was conducted on 167 consecutive patients presenting to our emergency department with acute STEMI. All patients were treated with primary percutaneous coronary intervention. Patients were grouped according to time of presentation: during regular hours (Monday to Friday 08:00 to 17:00) vs off hours (after 17:00 on weekdays and all hours on weekends). Baseline recorded variables included mode of presentation, transmission of prehospital ECG, and activation of Cath Alert system. RESULTS: Overall, the mean (SD) DBT was 69 (35) mins, with the majority of patients (n = 131, 78%) achieving the recommended DBT of 90 mins. The shortest DBT occurred in patients who arrived by emergency medical services with use of the prehospital ECG and Cath Alert system (53 (21) min), while those who arrived as a walk-in without use of emergency medical services had the longest DBT (105 (38) min; p<0.001). Compared to regular hours, presentation during off hours prolonged DBT in patients presenting via emergency medical services (75 (16) vs 53 (18) min, p = 0.03). With transmission of the prehospital ECG, the delay in DBT was improved among those presenting off hours, nullifying the adverse effect of off hour presentation (54 (21) vs 49 (22) min; p = 0.26). CONCLUSION: Variables such as time of day and mode of presentation have an impact on achieving currently recommended DBT in patients with STEMI. With the addition of each prehospital variable in succession-that is, arrival by emergency medical services, Cath Alert system, and the prehospital ECG-the DBT can be progressively shortened and the adverse "off hour effect" nullified.

Drug-eluting stent implantation in ST-elevation acute myocardial infarction: 'real world' 30-day and mid-term results.

Primary percutaneous coronary intervention (PCI) with stent implantation is the preferred method of reperfusion for ST-elevation acute myocardial infarction. Concern remains over the use of drug-eluting stents in the acute ST-elevation myocardial infarction setting, with limited published reports on their use for this application. We studied 64 consecutive patients presenting with an acute ST-elevation myocardial infarction who underwent mechanical reperfusion with implantation of a drug-eluting stent. Both sirolimus- and paclitaxel-eluting stents were used. Primary outcome was the occurrence of major adverse cardiac events, defined as death, nonfatal reinfarction or clinically driven target vessel revascularization. Post-procedural success was achieved in 63 patients (98%). In-hospital mortality was 1.6%. During a median follow-up of 234 days, there were no cases of stent thrombosis, reinfarction or reintervention. These findings conducted in a 'real world' practice setting in the United States demonstrate that drug-eluting stent implantation for acute ST-elevation myocardial infarction is safe and effective, with a low rate of major adverse cardiac events during mid-term follow-up.

Renal fibromuscular dysplasia in elderly persons.

Renal artery stenosis (RAS) is a significant cause of secondary hypertension, the progression of which can lead to renal insufficiency, uncontrolled hypertension, and even end-stage renal disease. The 2 most common forms of RAS are atherosclerotic renovascular disease and fibromuscular dysplasia (FMD). Atherosclerosis accounts for 90% of all cases of RAS and generally affects an elderly population. Conversely, FMD accounts for approximately 10% of all RAS cases and is described as affecting a younger population. Four cases of FMD in individuals older than 70 years are presented, in a period of 1 year at 1 facility. This case series calls into question the previously reported low prevalence of FMD in elderly persons. It is conceivable that renal artery investigation might be denied an elderly patient thought to have atherosclerotic disease. Because conventional angioplasty is considered the treatment of choice for patients with FMD because of the high response rate for uncontrolled hypertension, the prevalence of FMD in the elderly population should be reevaluated to detect and treat this population accordingly.

Successful use of sirolimus-eluting stents for treatment of ST-elevation acute myocardial infarction caused by left main coronary artery occlusion.

We describe an ST-elevation acute myocardial infarction involving the left main coronary artery in a middle-aged man who was treated by primary angioplasty with the use of sirolimus-eluting stents. To our knowledge, this is the 1st report of survival after sirolimus-eluting stent implantation in a patient with acute occlusion of the left main coronary artery. We discuss the case and review the literature.

Combination pharmacotherapy with reduced-dose fibrinolytic and platelet GP IIb/IIIa inhibition.

Combination fibrinolytic and antiplatelet therapy regimens may provide a means of inducing rapid reperfusion in patients requiring myocardial salvage after an acute myocardial infarction (AMI). This article describes case histories and a therapeutic regimen combining reteplase (5 U + 5 U double bolus) and abciximab (0.25 mg/kg bolus + 0.125 microg/kg/min infusion to a maximum of 10 microg/min for 12 h) for AMI patients before percutaneous coronary intervention (PCI). This medication regimen was used in the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) V clinical trial, for the medical treatment of AMI, resulting in decreased reinfarction rates with similar mortality and intracranial hemorrhage rates as compared to standard fibrinolytic therapy.